Cryptosporidium in Children with Diarrhea: A Hospital

RESEARCH BRIEF
Cryptosporidium in Children with Diarrhea: A Hospital-based Study
PURBASHA BERA, SHUKLA DAS, RUMPA SAHA, VG RAMACHANDRAN AND *DHEERAJ SHAH
From the Departments of Microbiology and *Pediatrics, University college of Medical Sciences and Guru Teg Bahadur Hospital,
Dilshad Garden, Delhi, India
Correspondence to:
Dr Purbasha Bera,
Department of Microbiology,
University College of Medical Sciences
and Guru Teg Bahadur Hospital,
Dilshad Garden, Delhi 110 095, India.
[email protected]
Received: January 24, 2014;
Initial review: February 28, 2014;
Accepted: September 19, 2014.
Objective: To estimate the proportionate contribution of Cryptosporidium to diarrhea in
under-five children, and to study its demographic and clinical associates
Methods: We collected stool specimens from children (age <5 yrs) suffering from diarrhea.
The specimen was examined on the same day by Kinyoun’s acid-fast staining for the
presence of Cryptosporidium parvum oocyst; rest of the sample was preserved for later
cryptosporidium antigen detection by commercially available ELISA kit.
Results: Out of 175 children with diarrhea, 48 (27.4%) had Cryptosporidium antigen in their
stool specimen. Gender, history of contact with domestic animal, hydration status,
breastfeeding and nutritional status were not significantly associated with cryptosporidium
infection in children with diarrhea.
Conclusion: Cryptosporidium is present in a significant portion of children suffering from
diarrhea in our setting. Antigen detection has much higher isolation rate than acid-fast
staining.
Keywords: Epidemiology, Prevalence, Protozoa.
C
Cryptosporidium parvum as 13% [4], a margin of error
of 5% with a 95% confidence interval, the calculated
sample size was 175 children. Acute diarrhea was
defined as three or more loose stools per day over a 72
hours period; diarrhea persisting for more than 14 days
was defined as persistent diarrhea [5,6]. Children with
known immunosuppression, history of receiving
antibiotics or antiparasitic drugs for current episode of
diarrhea, known food allergies, history of recurrent
hospitalization due to infections, history of intake of
steroids in last three months or history of infection with
unusual organisms, were excluded from our study. The
parents of these children were interviewed using a
pre-designed form for demographic, epidemiological
and clinical history. The stool sample was collected in a
clean, leak-proof container, and examined on the same
day by preparation of wet mount with lugol’s iodine
and by Kinyoun’s acid-fast staining for the presence
of C. parvum oocyst, after concentrating the sample by
formalin-ether sedimentation [7]. Rest of the stool
specimen was divided in two parts. One part was
processed for culture for detection of other enteric
pathogens and the other was preserved in 10% formalin
for antigen detection by commercially available
Cryptosporidium surface antigen detection ELISA kit
(DRG international Inc. USA). Data were analyzed by
SPSS 17.0. Qualitative data were compared by chisquare test or Fisher exact test, as applicable.
ryptosporidium is an obligate intracellular
protozoa that is a major cause of diarrheal
illness worldwide in both immunocompetent and immunocom-promised
children. Cryptosporidium was found to be the second
leading cause of moderate to severe diarrhea at five
sites in GEMS (Global Enteric Multi-Center Study)
study [1]. Children appear to be susceptible to serious
adverse consequences like stunting, lack of catch-up
growth, cognitive and physical developmental delay
even after asymptomatic infection with C. parvum [2].
Most available Indian data on Cryptosporidium have
focused on immunocompromised patients with limited
work on immunocompetent children who may also
suffer adverse consequences. Furthermore, most of the
data from India are based on acid-fast staining, which
has very low sensitivity [3]. The present study estimated
the prevalence of Cryptosporidium – using an ELISAbased antigen detection system – in stool samples of
immunocompetent children, presenting with acute or
persistent diarrhea.
METHODS
In this prospective study from April 2012 to March
2013, we included children under 5 years of age
suffering from acute or persistent diarrhea. The study
was approved by the Ethical committee of the
institution.
Assuming
the
prevalence
of
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CRYPTOSPORIDIUM IN CHILDHOOD DIARRHEA
reported a high prevalence rate (27.4%) of
Cryptosporidium infection. Sensitivity of microscopy
was poor in comparison to antigen detection by
ELISA.
R ESULTS
Out of 175 stool samples collected in our study, seven
were positive for oocyst of C. parvum using
Kinyoun’s acid-fast staining, and 48 (27.4%) were
positive for cryptosporidium antigen by ELISA. All
seven patients harbouring cryptosporidium oocyst
were positive for cryptosporidium antigen in the stool.
Similar high prevalence of this parasite in children
with diarrhea has been reported earlier from India [8]
and Bolivia [9]. Low sensitivity of microscopy may
be explained due to presence of less number of
parasites in children with intact immune response,
which inhibits further proliferation of parasites.
Among the cryptosporidium-positive children,
66.7% used municipal water supply for drinking;
10.4% and 8.3% were using water from well and tube
well, respectively. Only four children presented with
severe dehydration. History of contact with domestic
animal was present in only five children positive for
cryptosporidium antigen in their stool samples.
Contact with domestic animals as a significant
risk factor [10] was not seen in our study, as also
reported from Mexico [11] and Brazil [12]. Infection
rates in our study were not influenced by lack of
breastfeeding or source of drinking water. Unsafe
drinking water has earlier been reported as a risk
factor in a large outbreak of cryptosporidiosis in
Milwaukee Wisconsin in 1993 [13]. Although
malnutrition, especially stunting, has been significantly associated with cryptosporidiosis, in our
study it was not observed as a risk factor. Due to lack
of follow-up in our study, it is difficult to conclude as
to whether Cryptosporidium infection leads to
malnutrition or vice versa. Our study had limitations
of being hospital-based and without follow-up.
The relationship between the nutritional status and
cryptosporidiosis is summarized in Table I. Out of 48
cryptosporidium-positive patients, five and six
children had weight-for-age Z score between -2 to -3
and <-3, respectively.
In our study group, cryptosporidium-positive
samples were co-infected with Vibrio cholerae, 01
ogawa (2 cases), Salmonella choleraesuis (1 case)
and Giardia lambia cyst (1 case). Cryptosporidiumnegative five cases were culture positive for Vibrio
cholerae and one for Salmonella-typhimurium.
To conclude, infection with Cryptosporidium
species is prevalent in a significant proportion of
immunocompetent children suffering from diarrea in
urban Northern India. This parasite is an important
D ISCUSSION
This prospective study in urban Northern Indian
immunocompetent under-five children with diarrhea
TABLE I CLINICAL AND SOCIO-DEMOGRAPHIC PROFILE OF CHILDREN WITH AND WITHOUT CRYPTOSPORIDIOSIS
Variables
Cryptosporidiosis (n=48)
No Cryptosporidiosis (n=127)
47
121
1
6
–
–
No dehydration
23
76
–
0.304
Some dehydration
21
40
–
–
Acute diarrhea
Persistent diarrhea
Severe dehydration
Breastfeeding
Fever
Vomiting
OR (95% CI)
P value
0.43 (0.05- 3.66)
0.426
4
11
–
31
67
1.63 (0.82-3.24)
0.160
–
9
25
0.94 (0.40-2.2)
0.889
19
40
1.42 (0.72-2.84)
0.313
Abdominal pain
6
9
1.87 (0.63-5.58)
0.254
Abdominal distention
2
10
0.51 (0.11-2.41)
0.387
Nutritional status
WHZ, Mean(SD)
–0.80 (1.70)
–1.17 (1.90)
–
0.244
WAZ, Mean(SD)
–1.80 (1.54)
–2.14 (1.48)
–
0.179
HAZ, Mean(SD)
–1.88 (1.93)
–2.32 (1.54)
–
0.177
WHZ- Weight for height Z score; WAZ- Weight for age Z score; HAZ-Height for age Z score.
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WHAT THIS STUDY ADDS?
• Cryptosporidium infection is common in under-five children suffering from diarrhea in an urban setting from Northern
India.
etiological agent of acute gastroenteritis and diarrheal
illness among children. Prompt identification of this
agent by antigen detection should be an essential part
of studies investigating etiology of childhood
diarrhea. Efforts must be initiated to develop
facilities for cryptosporidium antigen detection at all
levels for proper diagnosis and management of
childhood diarrhea.
7.
8.
Funding: None; Competing interests: None stated
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